Sunday, June 30, 2013
Friday, June 28, 2013
A multi-national report on methods for institutional credentialing for spine radiosurgery
A multi-national report on methods for institutional credentialing for spine radiosurgery
Radiation Oncology - Latest Articles
Background: Stereotactic body radiotherapy and radiosurgery are rapidly emerging treatment options for both malignant and benign spine tumors. Proper institutional credentialing by physicians and medical physicists as well as other personnel is important for the safe and effective adoption of spine radiosurgery. This article describes the methods for institutional credentialing for spine radiosurgery at seven highly experienced international institutions. Methods: All institutions (n = 7) are members of the Elekta Spine Radiosurgery Research Consortium and have a dedicated research and clinical focus on image-guided spine radiosurgery. A questionnaire consisting of 24 items covering various aspects of institutional credentialing for spine radiosurgery was completed by all seven institutions. Results: Close agreement was observed in most aspects of spine radiosurgery credentialing at each institution. A formal credentialing process was believed to be important for the implementation of a new spine radiosurgery program, for patient safety and clinical outcomes. One institution has a written policy specific for spine radiosurgery credentialing, but all have an undocumented credentialing system in place. All institutions rely upon an in-house proctoring system for the training of both physicians and medical physicists. Four institutions require physicians and medical physicists to attend corporate sponsored training. Two of these 4 institutions also require attendance at a non-corporate sponsored academic society radiosurgery course. Corporate as well as non-corporate sponsored training were believed to be complimentary and both important for training. In 5 centers, all cases must be reviewed at a multidisciplinary conference prior to radiosurgery treatment. At 3 centers, neurosurgeons are not required to be involved in all cases if there is no evidence for instability or spinal cord compression. Backup physicians and physicists are required at only 1 institution, but all institutions have more than one specialist trained to perform spine radiosurgery. All centers believed that credentialing should also be device specific, and all believed that professional societies should formulate guidelines for institutions on the requirements for spine radiosurgery credentialing. Finally, in 4 institutions radiation therapists were required to attend corporate-sponsored device specific training for credentialing, and in only 1 institution were radiation therapists required to also attend academic society training for credentialing. Conclusions: This study represents the first multi-national report of the current practice of institutional credentialing for spine radiosurgery. Key methodologies for safe implementation and credentialing of spine radiosurgery have been identified. There is strong agreement among experienced centers that credentialing is an important component of the safe and effective implementation of a spine radiosurgery program.
Original Article: http://www.ro-journal.com/content/8/1/158
Multi-disciplinary management for patients with oligometastases to the brain: results of a 5 year cohort study
Multi-disciplinary management for patients with oligometastases to the brain: results of a 5 year cohort study
Radiation Oncology - Latest Articles
Background: The incidence of oligometastases to the brain in good performance status patients is increasing due to improvements in systemic therapy and MRI screening, but specific management pathways are often lacking. Methods: We established a multi-disciplinary brain metastases clinic with specific referral guidelines and standard follow-up for good prognosis patients with the view that improving the process of care may improve outcomes. We evaluated patient demographic and outcome data for patients first seen between February 2007 and November 2011. Results: The clinic was feasible to run and referrals were appropriate. 87% of patients referred received a localised therapy during their treatment course. 114 patients were seen and patient numbers increased during the 5 years that the clinic has been running as relationships between clinicians were developed. Median follow-up for those still alive was 23.1 months (6.1-79.1 months). Primary treatments were: surgery alone 52%, surgery plus whole brain radiotherapy (WBRT) 9%, radiosurgery 14%, WBRT alone 23%, supportive care 2%. 43% received subsequent treatment for brain metastases. 25%, 11% and 15% respectively developed local neurological progression only, new brain metastases only or both. Median overall survival following brain metastases diagnosis was 16.0 months (range 1--79.1 months). Breast (32%) and NSCLC (26%) were the most common primary tumours with median survivals of 26 and 16.9 months respectively (HR 0.6, p=0.07). Overall one year survival was 55% and two year survival 31.5%. 85 patients died of whom 37 (44%) had a neurological death. Conclusion: Careful patient selection and multi-disciplinary management identifies a subset of patients with oligometastatic brain disease who benefit from aggressive local treatment. A dedicated joint neurosurgical/ neuro-oncology clinic for such patients is feasible and effective. It also offers the opportunity to better define management strategies and further research in this field. Consideration should be given to defining specific management pathways for these patients within general oncology practice.
Original Article: http://www.ro-journal.com/content/8/1/156
Intraoperative Seizures During Awake Craniotomy: Incidence and Consequences: Analysis of 477 Patients
Intraoperative Seizures During Awake Craniotomy: Incidence and Consequences: Analysis of 477 Patients
Neurosurgery - Most Popular Articles
BACKGROUND:Awake craniotomy (AC) for removal of intra-axial brain tumors is a well-established procedure. However, the occurrence and consequences of intraoperative seizures during AC have not been well characterized. OBJECTIVE:To analyze the incidence, risk factors, and consequences of seizures during AC. METHODS:The database of AC at Tel Aviv Medical Center between 2003 to 2011 was reviewed. Occurrences of intraoperative seizures were analyzed with respect to medical history, medications, tumor characteristics, and postoperative outcome. RESULTS:Of the 549 ACs performed during the index period, 477 with complete records were identified. Sixty patients (12.6%) experienced intraoperative seizures. The AC procedure failed in 11 patients (2.3%) due to seizures. Patients with intraoperative seizures were significantly younger than nonseizing patients (45 ± 14 years vs 52 ± 16 years, P = .003), had a higher incidence of frontal lobe involvement (86% vs % 57%, P < .0001), and had higher prevalence of a history of seizures (P = .008). Short-term motor deterioration developed postoperatively in a higher percentage of patients with intraoperative seizures (20% vs 10.1%, P = .02) with a longer hospitalization period (4.0 ± 3.0 days vs 3.0 ± 3.0 days, P = .045). CONCLUSION:Although in most cases intraoperative seizures will not result in AC failure, the surgical team should be prepared to treat them promptly to avoid intractable seizures. Intraoperative seizures are more common in younger patients with a tumor in the frontal lobe and those with a history of seizures. Moreover, they are associated with a higher incidence of transient postoperative motor deterioration and protracted length of hospital stay. ABBREVIATIONS:AC, awake craniotomyAED, antiepileptic drugECoG, electrocorticographyOR, odds ratioOriginal Article: http://journals.lww.com/neurosurgery/Fulltext/2013/07000/Intraoperative_Seizures_During_Awake_Craniotomy__.17.aspx
The Effect of Emotion and Physician Communication Behaviors on Surrogates' Life-Sustaining Treatment Decisions: A Randomized Simulation Experiment*
The Effect of Emotion and Physician Communication Behaviors on Surrogates' Life-Sustaining Treatment Decisions: A Randomized Simulation Experiment*
Critical Care Medicine - Most Popular Articles
Objective:Surrogate decision makers for critically ill patients experience strong negative emotional states. Emotions influence risk perception, risk preferences, and decision making. We sought to explore the effect of emotional state and physician communication behaviors on surrogates' life-sustaining treatment decisions. Design:5 × 2 between-subject randomized factorial experiment. Setting:Web-based simulated interactive video meeting with an intensivist to discuss code status. Subjects:Community-based participants 35 and older who self-identified as the surrogate for a parent or spouse recruited from eight U.S. cities through public advertisements. Interventions:Block random assignment to emotion arousal manipulation and each of the four physician communication behaviors. Measurements and Main Results:Surrogate's code status decision (cardiopulmonary resuscitation vs do not resuscitate/allow natural death). Two hundred fifty-six of 373 respondents (69%) logged-in and were randomized: average age was 50; 70% were surrogates for a parent; 63.5% were women; 76% were white, 11% black, and 9% Asian; and 81% were college educated. When asked about code status, 56% chose cardiopulmonary resuscitation. The emotion arousal manipulation increased the score on depression-dejection scale (β = 1.76 [0.58 – 2.94]) but did not influence cardiopulmonary resuscitation choice. Physician attending to emotion and framing the decision as the patient's rather than the surrogate's did not influence cardiopulmonary resuscitation choice. Framing no cardiopulmonary resuscitation as the norm rather than cardiopulmonary resuscitation resulted in fewer surrogates choosing cardiopulmonary resuscitation (48% vs 64%, odds ratio, 0.52 [95% CI, 0.32–0.87]), as did framing the alternative to cardiopulmonary resuscitation as "allow natural death" rather than do not resuscitate (49% vs 61%, odds ratio, 0.58 [95% CI, 0.35–0.96]). Conclusions:Experimentally induced emotional state did not influence code status decisions, although small changes in physician communication behaviors substantially influenced this decision.Original Article: http://journals.lww.com/ccmjournal/Fulltext/2013/07000/The_Effect_of_Emotion_and_Physician_Communication.12.aspx
Thursday, June 27, 2013
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Wednesday, June 26, 2013
Cancer research in the United States: Dying by a thousand paper cuts
Cancer research in the United States: Dying by a thousand paper cuts
Cancer
The authors discuss cancer research in the United States and the implications of bureaucratic burdens on the conduct and cost of research and, consequently, the cost of drugs and health care. They propose potential remedial solutions.
Original Article: http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002/cncr.28193
Guillain-Barre Risk Unlikely After Vaccination (CME/CE)
Guillain-Barre Risk Unlikely After Vaccination (CME/CE)
MedPage Today Neurology
(MedPage Today) -- Guillain-Barre syndrome does not appear to be a risk following administration of several common vaccines, including seasonal trivalent inactivated influenza vaccines, researchers found.
Original Article: http://www.medpagetoday.com/InfectiousDisease/Vaccines/40057
Evaluation of High Ipsilateral Subventricular Zone Radiation Therapy Dose in Glioblastoma: A Pooled Analysis
Evaluation of High Ipsilateral Subventricular Zone Radiation Therapy Dose in Glioblastoma: A Pooled Analysis
International Journal of Radiation Oncology * Biology * Physics
Purpose: Cancer stem cells (CSCs) may play a role in the recurrence of glioblastoma. They are believed to originate from neural stem cells in the subventricular zone (SVZ). Because of their radioresistance, we hypothesized that high doses of radiation (>59.4 Gy) to the SVZ are necessary to control CSCs and improve progression-free survival (PFS) or overall survival (OS) in glioblastoma.Methods and Materials: 173 patients with glioblastoma pooled from 2 academic centers were treated with resection followed by chemoradiation therapy. The SVZ was segmented on computed tomography to calculate radiation doses delivered to the presumptive CSC niches. The relationships between high SVZ doses and PFS and OS were examined using Cox proportional hazards models. Five covariates were included to estimate their impact on PFS or OS: ipsilateral and contralateral SVZ doses, clinical target volume dose, age, and extent of resection.Results: Median PFS and OS were 10.4 and 19.6 months for the cohort. The mean ipsilateral SVZ, contralateral SVZ, and clinical target volume doses were 49.2, 35.2, and 60.1 Gy, respectively. Twenty-one patients who received high ipsilateral SVZ dose (>59.4 Gy) had significantly longer median PFS (12.6 vs 9.9 months, P=.042) and longer OS (25.8 vs 19.2 months, P=.173). On multivariate analysis, high radiation therapy doses to ipsilateral SVZ remained a statistically significant independent predictor of improved PFS but not of OS. The extent of surgery affected both PFS and OS on multivariate analysis.Conclusion: High radiation therapy doses to ipsilateral CSC niches are associated with improved PFS in glioblastoma.
Original Article: http://www.redjournal.org/article/PIIS0360301613000722/abstract?rss=yes
Multidose Stereotactic Radiosurgery (9 Gy × 3) of the Postoperative Resection Cavity for Treatment of Large Brain Metastases
Multidose Stereotactic Radiosurgery (9 Gy × 3) of the Postoperative Resection Cavity for Treatment of Large Brain Metastases
International Journal of Radiation Oncology * Biology * Physics
Purpose: To evaluate the clinical outcomes with linear accelerator-based multidose stereotactic radiosurgery (SRS) to large postoperative resection cavities in patients with large brain metastases.Methods and Materials: Between March 2005 to May 2012, 101 patients with a single brain metastasis were treated with surgery and multidose SRS (9 Gy × 3) for large resection cavities (>3 cm). The target volume was the resection cavity with the inclusion of a 2-mm margin. The median cavity volume was 17.5 cm3 (range, 12.6-35.7 cm3). The primary endpoint was local control. Secondary endpoints were survival and distant failure rates, cause of death, performance measurements, and toxicity of treatment.Results: With a median follow-up of 16 months (range, 6-44 months), the 1-year and 2-year actuarial survival rates were 69% and 34%, respectively. The 1-year and 2-year local control rates were 93% and 84%, with respective incidences of new distant brain metastases of 50% and 66%. Local control was similar for radiosensitive (non-small cell lung cancer and breast cancer) and radioresistant (melanoma and renal cell cancer) brain metastases. On multivariate Cox analysis stable extracranial disease, breast cancer histology, and Karnofsky performance status >70 were associated with significant survival benefit. Brain radionecrosis occurred in 9 patients (9%), being symptomatic in 5 patients (5%).Conclusions: Adjuvant multidose SRS to resection cavity represents an effective treatment option that achieves excellent local control and defers the use of whole-brain radiation therapy in selected patients with large brain metastases.
Original Article: http://www.redjournal.org/article/PIIS0360301613003611/abstract?rss=yes
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